MEDICARE: BRANDY L BURGESS, DDS, MS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	2006016233	MO

General Provider Information

NPI Number	:	1710343504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDY L BURGESS, DDS, MS, LLC

Provider Business Mailing Address
First Line	:	1276 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	636-223-7123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1276 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	636-223-7123
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. BRANDY BURGESS
Credential	:	DDS
Telephone Number	:	636-223-7123

Provider Enumeration Date	:	01/08/2016
Last Update Date	:	01/08/2016

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